Diagnostic radiology

Practice area 159 Clinical PRIVILEGE WHITE PAPER Diagnostic radiology Background According to the American Board of Medical Specialties (ABMS), a radiologist is a physician who uses imaging methodologies to diagnose and manage patients and provide therapeutic options. A diagnostic radiologist uses x-rays, ionizing radiation, radionuclides, ultrasound, electromagnetic radiation, and image-guided intervention to diagnose and treat disease. According to the ABMS and the Accreditation Council of Graduate Medical Education (ACGME), training to become a diagnostic radiologist takes a total of five years. That includes one year of clinical work followed by four years of radiology training. According to the ABMS, there are five subspecialties of diagnostic radiology in which physicians can also become certified. However, any physician who wishes to specialize in any of these five areas must first become certified in diagnostic radiology. The five areas are: Neuroradiology Nuclear radiology Pediatric radiology Vascular and interventional radiology Hospice and palliative medicine The ACGME, however, divides diagnostic radiology into nine subspecialty areas for the purposes of training and education. They are: Neuroradiology Musculoskeletal radiology Vascular and interventional radiology Cardiothoracic radiology Breast radiology Abdominal radiology Pediatric radiology Ultrasonography (including obstetrical and vascular ultrasound) Nuclear radiology (including PET and nuclear cardiology) Core privileges in diagnostic radiology include the ability to perform general diagnostic radiology (x-ray, radionuclides, ultrasound, and electromagnetic radiation) to diagnose Please replace Clinical Privilege White Paper, Diagnostic radiology Practice area 159, with this updated version. A supplement to Briefings on Credentialing 781/639-1872 05/10

and treat diseases of patients of all ages. Radiologists are responsible for communicating critical values and critical findings consistent with medical staff policy. Core privileges include but are not limited to: Bone densitometry CT of the head, neck, spine, body, and chest, including the heart, abdomen, pelvis, and extremities as well as their associated vasculatures Diagnostic nuclear radiology of the head, neck, spine, body, and chest, including the heart, abdomen, pelvis, and extremities as well as their associated vasculatures MRI of the head, neck, spine, body, and chest, including the heart, abdomen, pelvis, and extremities as well as their associated vasculatures Positron emission tomography (PET) Mammography (in accordance with MQSR-required qualifications) Routine imaging (e.g., interpretation of plain films, intravenous or retrograde pyelography, fluoroscopy, chest/abdomen, pelvis/gastrointestinal, and genitourinary diagnostic and therapeutic procedures) Image-guided biopsy, cyst aspiration, and procedures (e.g., lumbar puncture) Ultrasound Involved specialties Radiologists Positions of societies and academies ACR In its position statement, ACR Policy on Medical Staff Privileges, Exclusive Contracts, and Economic Credentialing, the American College of Radiology (ACR) states that radiologists with hospital medical staff appointments and clinical privileges should have the same rights as any other members of the hospital s medical staff. Further, those privileges comprise the right of medical staff members to provide specific patient care services in a manner consistent with licensure, education, and expertise. These rights also include the right of access to hospital resources, including equipment, facilities, and personnel necessary to exercise privileges effectively. The ACR states that hospital governing boards should abridge a physician s privileges only upon recommendation of the medical staff for reasons related to professional competence, adherence to appropriate standards 2 A supplement to Briefings on Credentialing 781/639-1872 05/10

of medical care, health status, or other parameters agreed on by the medical staff. The ACR also addresses the issue of economic credentialing. To protect the integrity of the credentialing and peer review process and to ensure high-quality patient care, the ACR asserts that decisions to grant or terminate clinical privileges should not be based on economic considerations that do not legitimately relate to a physician s professional competence. When economic criteria such as the perceived profitability of, or the types of patients in, a physician s practice take the place of a valid basis for granting privileges (e.g., the licensure, education, and expertise of an individual physician), patient welfare and physicians rights are compromised. The ACR states that economic credentialing includes not only the award of clinical privileges on the basis of financial considerations but also practices by which hospitals attempt to share in the revenues derived by radiologists in providing professional services to patients. Examples of economic credentialing include requiring radiologists to contribute a portion of their professional fees to the hospital in exchange for the right to provide radiology services, or requiring that radiologists purchase billing or other services from the hospital at prices that exceed the fair market value of those services. Any arrangement that would base clinical privileges primarily on factors other than quality can be construed as a form of economic credentialing. Positions of other interested parties ABR The American Board of Radiology (ABR) grants certification in diagnostic radiology to physicians who meet the ABR s qualifications. To become certified in diagnostic radiology by the ABR, candidates must have met the following requirements: One year in clinical training: The first postgraduate year must be accredited clinical training in internal medicine, pediatrics, surgery or surgical specialties, OB/GYN, neurology, family practice, emergency medicine, transitional year, or any combination of these. No more than a total of three months may be spent in radiology, radiation oncology, and/or pathology. All clinical training must be in an ACGME-, American Osteopathic Association (AOA), or Royal College of Physicians and Surgeons of Canada (RCPSC) approved program (or equivalent). A supplement to Briefings on Credentialing 781/639-1872 05/10 3

Four years in an approved diagnostic radiology program that includes: A minimum of four months out of the four-year program spent in nuclear medicine. Three months in mammography. No more than 12 months in any one discipline (including research). After July 1, 2010, up to 16 months in any one discipline will be accepted. Successful completion of written and oral components of the exam. Proof of a valid license in the state or territory where the physician practices. Basic cardiac life support certification. The ABR also grants certificates of added qualifications in the following subspecialties of diagnostic radiology: Hospice and palliative medicine Neuroradiology Nuclear radiology Pediatric radiology Vascular and interventional radiology AOA/AOBR The American Osteopathic Board of Radiology (AOBR) is authorized by the AOA to grant certification in diagnostic radiology to physicians who qualify. To become certified, applicants must: Be a graduate of an AOA-accredited college of osteopathic medicine Be licensed to practice in the state where practice is conducted Be able to show evidence of conformity to the standards set forth in the Code of Ethics of the AOA Be a member in good standing of the AOA or the Canadian Osteopathic Association for the two years immediately prior to the date of certification Have satisfactorily completed a one-year AOA-approved internship Have successfully completed four or more years of AOAapproved training in diagnostic radiology (for applicants beginning their residency training on July 1, 1989) or three or more years of AOA-approved training in radiology or diagnostic radiology (for applicants beginning their residency training prior to July 1, 1989) Complete the requirements of training and experience 4 A supplement to Briefings on Credentialing 781/639-1872 05/10

as stated in the Basic Standards for Residency Training in Diagnostic Radiology, which includes 700 hours of nuclear medicine training Pass all examination components of the certification process ACGME According to the ACGME s Program Requirements for Graduate Medical Education in Diagnostic Radiology, effective July 1, 2010, residency programs in diagnostic radiology should last four years, during which the maximum period of training in any one of the nine subspecialty areas of diagnostic radiology shall be 16 months. Those subspecialties are: Neuroradiology Musculoskeletal radiology Vascular and interventional radiology Cardiothoracic radiology Breast radiology Abdominal radiology Pediatric radiology Ultrasonography (including obstetrical and vascular ultrasound) Nuclear radiology (including PET and nuclear cardiology) In addition to the four years in diagnostic radiology, physicians must have completed one year of basic clinical training accredited by the ACGME, the RCPSC, or an equivalent organization. Training can be in internal medicine, pediatrics, surgery or surgical specialties, OB/GYN, neurology, family medicine, emergency medicine, or any combination of these. The clinical year may also comprise a transitional year accredited by the ACGME or equivalent organization. At the completion of a four-year program in diagnostic radiology, residents must have accomplished the following in regard to patient care skills: Be able to provide patient care through safe, efficient, appropriately utilized, quality-controlled diagnostic and/or interventional radiology techniques. Communicate effectively and in a timely manner the results of procedures, studies, and examinations to the referring physician and/or other appropriate individuals. Have a minimum of 700 hours (approximately four months) of training and experience in clinical nuclear medicine, which may include the required 80 hours of classroom and laboratory instruction. Have a minimum of 12 weeks of clinical rotations in A supplement to Briefings on Credentialing 781/639-1872 05/10 5

breast imaging. Each resident must have documentation of the interpretation/multi-reading of at least 240 mammograms within a six-month period during his or her last two years in the residency program. Have documented supervised experience in interventional procedures. This includes image-guided biopsies, drainage procedures, angioplasty, embolization and infusion procedures, and other percutaneous-interventional procedures. Have training and clinical experience in the acquisition and interpretation of conventional radiography, CT, MRI, angiography, and nuclear radiology examinations of the cardiovascular system (heart and great vessels). This training must include studies performed on both adults and children. Maintain current basic life support certification. Advanced cardiac life support training is recommended. Programs in diagnostic radiology must also include: Didactic (classroom and laboratory) training in each of the nine identified subspecialty areas, including the heart and coronary arteries. The content should include the following in all age groups: anatomy, physiology, disease processes, and imaging. At least 80 hours of specialized didactic training in: Diagnostic radiologic physics, instrumentation, and radiation biology Patient and medical personnel safety (i.e., radiation protection) The chemistry of byproduct material for medical use Biologic and pharmacologic actions of materials administered in diagnostic and therapeutic procedures Topics in safe handling, administration, and quality control of radionuclide doses used in clinical medicine Programs in diagnostic radiology must also include general didactic education in the following areas: Diagnostic radiologic physics and radiation biology Patient and medical personnel safety (i.e., radiation protection, MRI safety) Appropriate imaging utilization (proper sequencing, costbenefit analysis) Radiologic-pathologic correlation (this requirement may be satisfied by resident participation in a formal course on radiologic-pathologic correlation) 6 A supplement to Briefings on Credentialing 781/639-1872 05/10

Fundamentals of molecular imaging Biologic and pharmacologic actions of materials administered in diagnostic or therapeutic procedures Use of needles, catheters, and other devices employed in invasive image-based diagnostic and therapeutic procedures Socioeconomics of radiologic practice Professionalism and ethics The Joint Commission The Joint Commission (formerly JCAHO) has no formal position concerning the delineation of privileges for diagnostic radiology. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS.06.01.03). In the rationale for MS.06.01.03, The Joint Commission states that there must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS.06.01.07). In the EPs for standard MS.06.01.07, The Joint Commission says the information review and analysis process is clearly defined. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS.08.01.03). In the EPs for MS.08.01.03, The Joint Commission says there is a clearly defined process facilitating the evaluation of each A supplement to Briefings on Credentialing 781/639-1872 05/10 7

practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. CRC draft criteria Minimum threshold criteria for requesting core privileges in diagnostic radiology References Core privileges in radiology The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this practice area. Basic education: MD or DO Minimum formal training: Successful completion of an ACGME- or AOA-accredited residency in diagnostic radiology and/or current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification in radiology by the ABR or the AOBR. Required previous experience: Applicants for initial appointment must be able to demonstrate performance and interpretation of at least 200 general radiology examinations, 100 CT examinations, 100 magnetic resonance (MR) examinations, and 75 PET examinations, reflective of the scope of privileges requested, or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the previous 12 months. A letter of reference must come from the director of the applicant s training program in radiology. Alternatively, a letter of reference regarding competence should come from the chief of radiology at the institution where the applicant most recently practiced. Core privileges in diagnostic radiology include the ability to perform general diagnostic radiology (x-ray, radionuclides, ultrasound, and electromagnetic radiation) to diagnose and treat diseases of patients of all ages. Radiologists are responsible for communicating critical values and critical findings consistent with medical staff policy. Core privileges include but are not limited to: Bone densitometry CT of the head, neck, spine, body, and chest, including the heart, abdomen, pelvis, and extremities as well as their associated vasculatures Diagnostic nuclear radiology of the head, neck, spine, 8 A supplement to Briefings on Credentialing 781/639-1872 05/10

body, and chest, including the heart, abdomen, pelvis, and extremities as well as their associated vasculatures MRI of the head, neck, spine, body, and chest, including the heart, abdomen, pelvis, and extremities as well as their associated vasculatures PET Mammography (in accordance with MQSR-required qualifications) Routine imaging (e.g., interpretation of plain films, intravenous or retrograde pyelography, fluoroscopy, chest/ abdomen, pelvis/gastrointestinal, and genitourinary diagnostic and therapeutic procedures) Image-guided biopsy, cyst aspiration, and procedures (e.g., lumbar puncture) Ultrasound Special requests in radiology For each special request, threshold criteria (e.g., additional training or completion of a recognized course and required experience) must be established. Special requests include but are not limited to: Breast cryoablation Cardiovascular MR Cardiac CT and CT angiogram Percutaneous vertebroplasty Balloon kyphoplasty Performance of carotid duplex Transcranial Doppler ultrasonography Percutaneous lumbar discectomy Stereotactic core-cut breast biopsy Endovascular repair of thoracic and abdominal aortic aneurysm in conjunction with qualified surgeon Peripheral vascular interventions to include diagnostic and therapeutic angiography, angioplasty, and stenting arterial, venous, grafts, and fistulas (excluding carotid stenting and intracranial intervention) Percutaneous thrombolysis/thrombectomy Carotid stenting Administration of sedation and analgesia Reappointment Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanisms. Applicants for reappointment must possess current demonstrated A supplement to Briefings on Credentialing 781/639-1872 05/10 9

competence and an adequate volume of experience (400 general radiology examinations, 200 CT examinations, 200 MR examinations, 150 PET examinations) with acceptable results, reflective of the scope of privileges requested, for the previous 24 months based on results of ongoing professional practice evaluation and outcomes. In addition, continuing education related to diagnostic radiology should be required. For more information Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL 60654 Telephone: 312/755-5000 Fax: 312/755-7498 Web site: www.acgme.org American Board of Medical Specialties 1007 Church Street, Suite 404 Evanston, IL 60201-5913 Telephone: 847/491-9091 or 800/776-2378 Fax: 847/328-3596 Web site: www.abms.org American Board of Radiology 5441 East Williams Boulevard, Suite 200 Tucson, AZ 85711 Telephone: 520/790-2900 Fax: 520/790-3200 Web site: www.theabr.org American College of Radiology 1891 Preston Drive Reston, VA 20191 Telephone: 703/648-8900 Web site: www.acr.org American Osteopathic Association 142 East Ontario Street Chicago, IL 60611 Telephone: 800/621-1773 Fax: 312/202-8200 Web site: www.osteopathic.org 10 A supplement to Briefings on Credentialing 781/639-1872 05/10

American Osteopathic Board of Radiology 119 East Second Street Milan, MO 63556 Telephone: 660/265-4011 Fax: 660/265-3494 Web site: www.aocr.org The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181 Telephone: 630/792-5000 Fax: 630/792-5005 Web site: www.jointcommission.org A supplement to Briefings on Credentialing 781/639-1872 05/10 11

Privilege request form Diagnostic radiology To be eligible to request clinical privileges in diagnostic radiology, an applicant must meet the following minimum threshold criteria: Basic education: MD or DO Minimum formal training: Successful completion of an ACGME- or AOA-accredited residency in diagnostic radiology and/or current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification in radiology by the ABR or the AOBR. Required previous experience: Applicants for initial appointment must be able to demonstrate performance and interpretation of at least 200 general radiology examinations, 100 CT examinations, 100 MR examinations, and 75 PET examinations, reflective of the scope of privileges requested, or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the previous 12 months. References: A letter of reference must come from the director of the applicant s training program in radiology. Alternatively, a letter of reference regarding competence should come from the chief of radiology at the institution where the applicant most recently practiced. Core privileges in radiology: Core privileges in diagnostic radiology include the ability to perform general diagnostic radiology (x-ray, radionuclides, ultrasound, and electromagnetic radiation) to diagnose and treat diseases of patients of all ages. Radiologists are responsible for communicating critical values and critical findings consistent with medical staff policy. Core privileges include but are not limited to: Bone densitometry CT of the head, neck, spine, body, and chest, including the heart, abdomen, pelvis, and extremities as well as their associated vasculatures Diagnostic nuclear radiology of the head, neck, spine, body, and chest, including the heart, abdomen, pelvis, and extremities as well as their associated vasculatures MRI of the head, neck, spine, body, and chest, including the heart, abdomen, pelvis, and extremities as well as their associated vasculatures PET Mammography (in accordance with MQSR-required qualifications) Routine imaging (e.g., interpretation of plain films, intravenous or retrograde pyelography, fluoroscopy, chest/abdomen, pelvis/gastrointestinal, and genitourinary diagnostic and therapeutic procedures) Image-guided biopsy, cyst aspiration, and procedures (e.g., lumbar puncture) Ultrasound 12 A supplement to Briefings on Credentialing 781/639-1872 05/10

Reappointment: Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanisms. Applicants for reappointment must possess current demonstrated competence and an adequate volume of experience (400 general radiology examinations, 200 CT examinations, 200 MR examinations, 150 PET examinations) with acceptable results, reflective of the scope of privileges requested, for the previous 24 months based on results of ongoing professional practice evaluation and outcomes. In addition, continuing education related to diagnostic radiology should be required. I understand that by making this request, I am bound by the applicable bylaws or policies of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this request. Physician s signature: Typed or printed name: Date: A supplement to Briefings on Credentialing 781/639-1872 05/10 13

14 A supplement to Briefings on Credentialing 781/639-1872 05/10

A supplement to Briefings on Credentialing 781/639-1872 05/10 15

Editorial Advisory Board Clinical Privilege White Papers Associate Group Publisher: Erin Callahan, ecallahan@hcpro.com Associate Editor: Julie McCoy, jmccoy@hcpro.com William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, GA Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, TX Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, CA Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, AZ Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, MO Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Marblehead, MA Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Marblehead, MA The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2010 HCPro, Inc., Marblehead, MA 01945. 16 A supplement to Briefings on Credentialing 781/639-1872 05/10